The No Surprises Act’s arbitration process is under more pressure than at any point since it launched in 2022. This fall, federal regulators pulled two arbitration firms from the system, a co-author of the law moved to scrap arbitration altogether, and new data put the process’s four-year cost at $22.4 billion.
Here is a roundup of the No Surprises Act developments this fall:
Regulators and lawmakers
1. Feds deny recertification to two arbitrators. HHS and the Labor and Treasury departments denied recertification Nov. 4 for two independent dispute resolution entities: Island Peer Review Organization, known as IPRO, and Network Medical Review Co. A CMS spokesperson told The New York Times the entities “did not substantially comply” with performance standards during their current terms. Neither can accept new disputes, and both have 30 business days to appeal. Parties with open disputes before either entity should expect guidance on next steps.
2. More arbitrators face review. Arbitrator contracts run five years, and the government is reviewing those awarded in 2022. Five entities submitted recertification applications, and three more entered the public petition period after payer and employer groups weighed in.
3. Payers and employers push for a pause. The Coalition Against Surprise Medical Billing and the ERISA Industry Committee sent letters to federal officials in late October, asking regulators to pause recertification until tougher standards are in place and to open a 30-day comment period before any decision. ERIC said some entities appear to consistently favor high-volume initiating parties and urged CMS to weigh how often entities accept ineligible disputes.
4. A No Surprises Act author moves to scrap arbitration. Rep. Frank Pallone Jr., D-N.J., ranking member of the House Energy and Commerce Committee, introduced the Lower Premiums, Faster Payments Act in October. The bill would replace independent dispute resolution with a payment benchmark tied to the median in-network rate and require payment within 30 days of a claim. Committee Democrats said 10 provider groups filed about 67% of the 2.5 million disputes initiated in 2025, and arbitration fees hit $1.3 billion that year, up from $885 million across 2022 through 2024 combined.
5. An enforcement bill waits on the other side. The bipartisan No Surprises Act Enforcement Act would add penalties and interest for plans that miss the law’s 30-day deadline to pay arbitration awards. Rep. Greg Murphy, MD, R-N.C., sponsors the House version, and Sens. Michael Bennet, D-Colo., and Roger Marshall, MD, R-Kan., sponsor the Senate version. The American College of Radiology, American College of Emergency Physicians and American Society of Anesthesiologists back it.
In the courts
6.. A second appeals court blocks provider suits to collect awards. On Sept. 17, the 2nd U.S. Circuit Court of Appeals ruled in East Coast Advanced Plastic Surgery v. Cigna Health and Life Insurance Co. that providers cannot sue insurers to enforce unpaid IDR awards. The breast reconstruction practice had won more than $3 million in awards against Cigna, which had made no payments on them; Cigna alleges the practice billed fraudulently. The decision follows the 5th Circuit’s 2025 Guardian Flight ruling, which the Supreme Court declined to review in January. Enforcement now rests largely with federal and state regulators in New York, Connecticut, Vermont, Texas, Louisiana and Mississippi.
7. SpecialtyCare sues Anthem in two more circuits. Brentwood, Tenn.-based SpecialtyCare and two affiliated physician groups filed suits against Anthem in October in federal courts in Virginia and Colorado — circuits that have not yet ruled on the question. The Virginia complaint says the groups won 1,443 awards worth about $2.75 million against two Anthem plans, which had paid about $249,800 as of Oct. 15. The Colorado suit alleges Anthem paid about $107,218 of $608,652 in awards. Anthem said it will continue to defend against these actions while supporting reforms that strengthen eligibility standards.
8. A Connecticut case tests the new 2nd Circuit precedent. A pending air ambulance lawsuit against Aetna and Cigna, where a federal judge in 2025 became the first to recognize a private right to enforce IDR awards, now sits under the 2nd Circuit’s ruling. In Sept. 28 briefs, Cigna argued the appellate decision forecloses the claim, while the providers said they are owed about $5.07 million by Aetna and $5.39 million by Cigna. Attorneys who represent payers said the Supreme Court is unlikely to take up the issue unless another circuit sides with providers.
The numbers driving the debate
9. Arbitration’s four-year tab: $22.4 billion. A Georgetown University analysis found the independent dispute resolution system cost $22.4 billion from 2022 through 2025. Awards to providers reached nearly $15 billion in 2025 alone, according to House Energy and Commerce Committee Democrats, and the New York State Employee Plan named arbitration awards as the main driver of its 10% premium increase this year.
10. Win rates swing by arbitrator. Physicians win more than 85% of disputes on average, but the rate ranges from 62% to 97% depending on the arbitration firm, The New York Times reported Nov. 4. In the fourth quarter of 2025, one firm’s median award to winning physicians was 601% of the QPA, while another’s was 159%. The 17 contracted firms set their own fees of $425 to $800 per dispute and collectively earned $742 million from 2022 through 2025.
11. Surgical assistants out-earn surgeons. Some surgical assistants are filing for arbitration separately from surgeons and winning far more than in-network rates. In March, a Dallas surgical assistant earned $50,456 through arbitration for a prostate removal, while the surgeon on the case earned $1,843. Assistants typically earn about 16% of the surgeon’s fee.
12. Neurology and surgery top payout multiples. Disputes involving neurology and neuromuscular codes, which include neuromonitoring, had a median prevailing offer of 2,394% of the QPA in the third quarter of 2025 and 2,585% in the fourth, according to CMS data. Surgical disputes ranked next, at 1,449% and 1,503% of QPA across roughly 53,000 to 56,000 determinations each quarter.
13. Volume keeps climbing as provider win rates dip. Providers started 2.6 million disputes in 2025, up 77% from 2024, and the median prevailing provider award was 445% of the QPA. Providers won about 85% of determinations in the second half of 2025, down from 88% in the first half. CMS has closed 664 complaints against payers for late payment of awards since 2022, compared with about 1.15 million determinations in the second half of 2025 alone.
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